Upper Bleph + Under Eye Filler? (Photo)

Question

Hello - I am a 40 yo female looking for eye rejuvenation. I have some hooding in my upper lids and hallowing on the lower lid. Am i good candidate for an upper bleph and under eye filler? I am concerned about the safety of the under eye filler since i've heard so many horror stories. I'm also concerned about possible scarring for the upper bleph due to my skin tone. Are these concerns valid?

Gary M. Horndeski, MD · Answer

You are an excellent candidate for an upper blepharoplasty.  In terms of the lower eyelids, you may benefit from fat transposition from blepharoplasty or fillers.

Best Wishes,

Gary Horndeski, M.D.

Thomas A. Mustoe, MD, FACS · Answer

I think you are a good candidate for upper blepharoplasty and lower eyelid fat transfer to which gives a more natural and long lasting result if done by a surgeon with extensive experience. The upper lids do not cause problematic scarring even in Katie to if color. The incision should be precisely in the natural crease and not be visible except as faint line only visible with the eyes closed

Leland Deane, MD, FACS · Answer

Thank you for your questions. From your photos, I can make some general recommendation. First, consider that the upper eyelid fullness that you have is, to a large degree, good not bad and is a sign of a youthful eyelid. Any upper lid surgery should be very conservative to avoid a 'hollowed out' look which is too often done and looks awful. Also, you upper eyelid skin excess is quite mild, in my opinion.

The lower lid sagging/hollowed appearance is also mild but might benefit from blepharoplasty but this also has to be done by an experienced surgeon who would explain things to you in consultation. I have good success with patients your age with this condition.

Never, never do any sort of lower lid or 'under eye' filler/fat or the like. Not only is the effect (if it works) temporary, but the risk of blindness is present and, although rare, is pretty much irreversible and there is no proven way to avoid this. So, in my mind, that takes even the idea of any under eye filler off the table.

Hope this helps.

Kenneth D. Steinsapir, MD · Answer

The desire to look better is natural and understandable. When you consult my colleagues, irrespective of their particular speciality ( oculoplastics, facial plastics, general plastics, or dermatology), more than likely they will not understand your objective. You won't be alone. Lets be honest, your goal in considering these procedures is to be transformed into a more beautiful self. This is basically the mythic quest of anyone seeking aesthetic surgery and services. Accomplishing this goal should be the mission of any potential surgeon you see but that is sadly not how things work. When you ask for an upper blepharoplasty, more than likely they will not even examine your eyelids. I know because I fix so many eyelids after unsatisfactory eyelid surgery. Instead they will speak to you and tell you that you are a great candidate for eyelid surgery and fillers. That is unfortunate because the examination of the eyelids is very important.  If they actually examined your eyes they might discover that you have early upper eyelid ptosis with a compensatory eyebrow elevation. The basis for the mild upper eyelid ptosis is partial central levator aponeurosis disinsertion with loss of a hard upper eyelid crease (accounts for the slight looseness of the upper eyelid platform skin. Assuming you have not reversed your images (very common) you hold your left eyebrow slightly higher than the right. What happens all too commonly with upper blepharoplasty is that the incision is placed at the natural crease but that will be too high. In some cases that could be between 10 and 14 mm.  Combined with a failure to recognize the evolving levator disinsertion, the upper eyelid will look hollow and skeletonized. More so when upper eyelid fat and skin are removed even when done "conservatively." Upper fold volume makes up look youthful. Then the fold is removed by the well meaning eyelid surgeon you will shocked and disappointed by the result. It will make you look older rather than transformed. What you need is a very thoughtful upper eyelid reconstruction with a low new crease at 6 or 7 mm with a repair of the disinserting levator disinsertion. This is very similar to an anterior levator ptosis repair but you really do not need much of any ptosis repair, rather you need the tendon to have a strong attachment to the upper eyelid tarsus. The eyelid platform skin length is carefully adjusted to snug this skin to the new hard upper eyelid crease. The amount of post operative eyelid platform skin is not something that should be left to the discretion of the surgeon. You need to have an explicit conversation with your potential surgeon about the design of this. Currently this is not uniform but if there is too much eyelid platform exposure under the fold edge you will be very unhappy.  Generally I recommend something in the 2.5 to 3 mm range so you have a place to hold make up. More than this begins to look excessive. With stabilization of the upper eyelid tendon, the eyebrows will relax and look for serene and relaxed which is understood as more youthful. I do think you could benefit from undereye filler-less is more. Only use Restylane for this location. It is a fussy service that is worth traveling for. If you are using a lash growth serum (Latisse, isopropyl cloprostenate, Jamaican castor bean oil) are harmful to the upper eyelid fat-please don't these products. Hope this helps.

Zoran Potparic, MD · Answer

It appears that conservative upper blepharoplasty may benefit you. Considering lower eyelids, it has been our experience in the past 20 years that combination of micro and nano fat grafts works better than fillers. Hope this helps.

Paul Phelps, MD, FACS · Answer

We have many patients who successfully undergo upper blepharoplasty despite having skin of color. There are several things that can be done to minimize the scar after surgery, including the use of silicone gel after the initial wound heals. We have patients start this after around 2 weeks when scarring is a concern. Also, the upper blepharoplasty incision is made in the eyelid crease, so this is generally easy to hide when the surgery is done well. Regarding lower eyelid filler, it is a topic which is pretty controversial. In my experience, it is only around 10% of patients who are good candidates for under eye filler. The vast majority of patients I see would have preferred if they were never treated with under eye filler.

Jared Blau, MD · Answer

Thank you for uploading the photos. You have some hooding of the upper eyelid, which is mild dermatochalasis. Well-addressed with an upper blepharoplasty, which is done in the office, you go home an hour later. The scar usually heals really well on the upper eyelid, of all skin tones. A knowledgeable surgeon puts the scar right in the eyelid crease, so even it the scar were bright green, it would be mostly hidden by the natural eye crease, especially when the eye is open which is 90% + of the time. I don’t recommend under eye filler

William Portuese, MD · Answer

From the pictures presented, you are only a candidate for an upper lid blepharoplasty. We do not recommend fillers in the lower lids, and your lower lids look great anyway  In our practice, an upper blepharoplasty can be performed under local anesthesia as an outpatient procedure, which takes about a half an hour. The incision is located directly in your upper eyelid crease

Kenneth R. Francis, MD, FACS · Answer

Dear Jani,
Yes, and yes.  You are a good candidate for an upper blepharoplasty and lower eyelid filler.  And your concerns are valid.  Correcting lower eyelid hollowing with fillers is challenging, which is why you've heard horror stories.  Alot of it is unqualified practitioners infringing on the world of aesthetic surgery/medicine.  But the lower lid area is a very sensitive and reactive place and even the best injector can create problems.  So, choose your injector wisely and carefully.  The upper eyelid usually scars indetectably with upper blepharoplasty.  But again, everyone scars differently, and could you develop pigmentation in a scar with your skin tone, of course.  The odds are against it fortunately, which is why so many blepharoplasties are performed each year.  Seek consulatation with an American Board of Plastic Surgery board certified plastic surgeon for an examination and discussion of your goals and options.  Good luck!

Karol A. Gutowski, MD, FACS · Answer

Your concerns are valid as there is always a scar with upper eyelid surgery. However, in most cases it is very well hidden and fades in 6 to 12 months. In darker skin patients, it may take a little longer but it is rare to be a problem.

With under eyelid filler it is important to use small amounts and go to a skilled injector. This procedure may not be for every one since in some cases, there is swelling which may require the filler to be reversed.

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